A 7‐year‐old with extravaginal torsion of an undescended testicle in the left inguinal region: The first case report from Syria

Key Clinical Message The incidence of undescended testicles torsion in a 7‐year‐old is rare, making it a clinically unusual occurrence. Emphasizing the importance of thorough urogenital assessments in children, particularly in underserved communities, is critical to prevent serious complications like testicular gangrene.


| DIFFERENTIAL DIAGNOSIS, INVESTIGATIONS, AND TREATMENT
A complete blood count (CBC) showed elevated white blood cells (WBCs), particularly granular cells, which were 10.4 × 10 3 /μl, and other laboratory test results were normal.Ultrasonography and color Doppler demonstrated that the left testis did not exist and was found in the left inguinal region, measuring (15.2 × 12) mm, and had no blood flow in the testis and hypoechoic pattern.
The right testis measured (18.8 × 9.1) mm was in the scrotum, and had significant blood flow and moderate echogenic pattern (Figure 2).The initial diagnosis was torsion of the undescended left testis.Under general anesthesia, a left inguinal incision was performed, revealing extravaginal testicular torsion (two round) inside the external inguinal ring, accompanied by testicular gangrene, with free fluid adhering to the adjacent tissue.After testicular examination, an orchidectomy was performed (Figure 3, Video S1).

| OUTCOME AND FOLLOW-UP
The patient was discharged in good condition the next day following surgery.

| DISCUSSION
Undescended testicle, or cryptorchidism, is a definition used to describe a testicle that remains in its development trajectory rather than in the scrotum. 1 Delasiauve described the first case of undescended testicular torsion in 1840.An undescended testicle can be found in the upper scrotum, superficial inguinal pouch, inguinal canal, or abdomen.Approximately 70% of undescended testicle cases are palpable.Approximately 30% of the nonpalpable testes are located in the inguinal-scrotal region, 55% are intra-abdominal, and 15% are absent or disappeared. 5he incidence of undescended testicles is 0.8%-1% in adults and children older than 1 year, with approximately 20% of these testes found intra-abdominally. 4 Researchers currently have no idea of the incidence or relative risk of torsion in an undescended testicle.According to many studies, torsion is more likely to occur in undescended testicle than in testes that have completely descended.One study suggested that the risk of torsion in cryptorchid testis is 10 times higher. 5It is unknown what pathophysiology contributes to the increased risk; some hypothesize that this difference is related to the ability of the spermatic cord to fully extend, while others propose that the heavier weight of the undescended testicle is the reason for torsion.In descended testes, torsion is correlated with the patency of the vaginal process.][4] An inguinal testicular patient presented with inguinal pain, swelling, erythema, vomiting, abdominal pain, and inconsolable crying.The most significant consequences of cryptorchidism include a high incidence of testicular cancer and a high rate of infertility. 4Torsion of an undescended testicle can be difficult to diagnose because it may mimic other, more common disorders such as appendicitis, acute abdomen, and incarcerated hernia.Surgery is frequently delayed as a result of diagnostic confusion. 6It was feasible to perform color Doppler and ultrasonography and complete genitourinary examinations to confirm the diagnosis without avoiding critical surgical investigations. 1,4The recommended approach for treating probable testicular torsion is rapid surgical exploration, regardless of where the testis is located. 1 The recommended period for surgical exploration and orchidopexy is between 6 months and 18 months of age, as this is when the probability of a spontaneous descent becomes less likely. 7rchiectomy is recommended if testicular necrosis has been observed and if there is no blood flow. 8In our case, we presented a 7-year-old child who had undescended testicle torsion in inguinal region, which is uncommon in this age range.There has not been any urogenital examination since the patient's birth due to poverty and neglect.The patient's symptoms were confirmed by ultrasound, which confirmed that the left testicle was torsion and located in the inguinal area.Additionally, color Doppler imaging showed no blood flow inside the testis.Surgical exploration revealed extravaginal testicular torsion, and testicular gangrene.An orchiectomy is done with the parent's consent.After the orchiectomy, the patient recovered well.

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I G U R E 1 (A) Frontal view; (B) Lateral view.Physical examination revealed the left inguinal region swelling and tenderness.F I G U R E 2 (A-C) The Doppler color scan demonstrated that the left testis in the inguinal area had a hyperechoic pattern, no blood flow, and excess fluid around it, and the left epididymis had a high blood flow and a hypoechoic pattern.(D, E) These figures demonstrate the right testis and epididymis by ultrasonography.(F) This figure demonstrates the difference between right and left testis.

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I G U R E 3 (A-C) Torsion testicle extraction following left inguinal incision.(D) Examining and separating the testicle from adjacent tissue.(E) Orchidectomy.